Inconsistencies in self-reported diabetes in a large panel study: the Survey of Health, Ageing and Retirement in Europe (SHARE).

BACKGROUND: The validity of self-reported chronic conditions has been assessed by comparing them with medical records or register data in several studies. However, the reliability of self-reports of chronic diseases has less often been examined. Our aim was to assess the proportion and determinants of inconsistent self-reports of diabetes in a long panel study. METHODS: SHARE (Survey of Health, Ageing and Retirement in Europe) includes 140,000 persons aged ≥ 50 years from 28 European countries and Israel. We used data from waves 1 to 7 (except wave 3) collected between 2004 and 2017. Diabetes was assessed by self-report. An inconsistent report for diabetes was defined as reporting the condition in one wave, but denying it in at least one later wave. The analysis data set included 13,179 persons who reported diabetes, and answered the question about diabetes in at least one later wave. Log-binomial regression models were fitted to estimate crude and adjusted relative risks (RR) with 95% confidence intervals (CI) for the associations between various exposure variables and inconsistent report of diabetes. RESULTS: The proportion of persons with inconsistent self-reports of diabetes was 33.0% (95% CI: 32.2%-33.8%). Inconsistencies occurred less often in persons taking antidiabetic drugs (RR = 0.53 (0.53-0.56)), persons with BMI ≥ 35 kg/m2 versus BMI < 25 kg/m2 (RR = 0.70, (0.64-0.77)), and poor versus excellent subjective health (RR = 0.87 (0.75-1.01)). Inconsistencies occurred more often in older persons (RR = 1.15 (1.12-1.18) per 10 years increase of age), and persons not reporting their age at diabetes onset (RR = 1.38 (1.31-1.45)). CONCLUSION: In SHARE, inconsistent self-report of diabetes is frequent. Consistent reports are more likely for persons whose characteristics make diabetes more salient, like intake of antidiabetic medication, obesity, and poor subjective health. However, lack of attention in answering the questions, and poor wording of the items may also play a role.

Binding and detoxification efficiency of albumin decline after haemodialysis.

BACKGROUND: Albumin, as the most abundant plasma protein, represents a target structure for both drug and physicochemical therapeutic approaches to eliminate uraemic toxins more efficiently. Potentially, this approach could reduce mortality of haemodialysis patients. However, little is known about albumin functional properties in these patients and its alteration by haemodialysis treatment. METHODS: The binding and detoxification efficiency of albumin were assessed by electron paramagnetic resonance spectroscopy using a spin-labelled fatty acid. Binding efficiency (BE) reflects strength and amount of bound fatty acids under certain ethanol concentration. Detoxification efficiency (DTE) reflects the molecular flexibility of the patient's albumin molecule, thus the ability to change the conformation depending on ethanol concentration. Percentage of BE and DTE are depicted in relation to healthy individuals (100%). RESULTS: Fifty-eight patients (59% male, median age 68 years, median time on haemodialysis 32 months) were included in the study. Before haemodialysis treatment, albumin binding and detoxification efficiency were substantially below healthy individuals [median BE 52% (interquartile range, IQR, 45%-59%); median DTE 38% (IQR 32-49%)]. After haemodialysis treatment, median BE and DTE significantly decreased [BE 28% (IQR 20-41%); DTE 11% (IQR 7%-27%; P < .001)]. BE and DTE decline after haemodialysis was not dependent on age, sex or treatment modalities, but was to a certain extent on the level of non-esterified fatty acids. CONCLUSION: Albumin binding and detoxification efficiency of fatty acids in maintenance haemodialysis patients were substantially below those in healthy individuals and even declined after dialysis treatment. These findings might be helpful when considering new therapeutic approaches in maintenance haemodialysis patients.

Effect of serum creatinine difference between the Jaffe and the enzymatic method on kidney disease detection and staging.

Background: Serum creatinine (SCr), mainly determined by the Jaffe or an enzymatic method, is the central marker to assess kidney function. Deviations between these two methods may affect the diagnosis and staging of acute kidney injury (AKI) and chronic kidney disease (CKD). Methods: The results of the first parallel SCr measurement (Jaffe and enzymatic method) of adult in- and outpatients in the same serum sample at the University Hospital Essen (Essen, Germany) between 2020-2022 were retrospectively evaluated. A Bland-Altman plot with 95% limits of agreement (LoAs) was used to assess the difference between the Jaffe and the enzymatic SCr (eSCr) method. We used the 2009 Chronic Kidney Disease Epidemiology Collaboration equation for determination of estimated glomerular filtration rate (eGFR) according to the Kidney Disease: Improving Global Outcomes guidelines. Results: A total of 41 144 parallel SCr measurements were evaluated. On average, Jaffe SCr was 0.07 mg/dl higher than eSCr (LoA -0.12; 0.25 mg/dl). In 19% of all cases there was a different CKD stage when comparing eGFR between both SCr methods, of which 98% resulted in a more severe CKD stage determined with Jaffe SCr. In 1.6% of all cases Jaffe SCr was ≥0.3 mg/dl higher than eSCr. Conclusion: The present study showed that methods of SCr measurement may affect both the diagnosis and staging of AKI and CKD. This must be taken into account when interpreting measurements of renal function in everyday clinical practice, but also when planning and comparing studies on renal diseases. One should therefore stay with one method for SCr measurement, preferably with the enzymatic method.

Association between number of children and incident heart disease and stroke in parents - results from the Survey of Health, Ageing and Retirement in Europe (SHARE).

BACKGROUND: In former studies, parity was associated with adverse cardiovascular outcomes in parents. This study aims to extend the limited existing data regarding the association between the number of children and heart disease and/or stroke in a large longitudinal study in different European countries in both men and women. METHODS: For 42 075 subjects (18 080 men, 23 995 women; median age 58 years (interquartile range: 53 to 65)) from 19 European countries and Israel in the Survey of Health, Ageing and Retirement in Europe (SHARE), odds ratios (OR) for the association between number of children and incident self-reported heart disease and/or stroke (HDS) were estimated using logistic regression analyses. Persons with one or two children were used as reference. The final model was adjusted for baseline age, sex, education, region, and marital status. All analyses were stratified by sex. RESULTS: Women with seven or more children had the highest OR for the association between the number of children and incident HDS (OR = 2.12 [95% CI: 1.51 to 2.98]), while men with six children showed the highest OR (OR = 1.62 [1.13 to 2.33]). Stratified by education, across all education levels, men and women with five or more children had the highest ORs for this association. The highest OR was observed in both women and men in the group with primary education (OR = 1.66 [1.29 to 2.15] and OR = 1.60 [1.19 to 2.14], respectively). Stratified by region, both men and women with five or more children showed the highest ORs in Southern Europe (OR = 2.07 [1.52 to 2.82] and OR = 1.75 [1.25 to 2.44], respectively). CONCLUSION: In this long-term follow-up study in various countries in Europe and Israel we found a positive association between number of children and incident HDS. This association was more pronounced in lower educated subjects and showed regional variations.

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care.

BACKGROUND: Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation. METHODS: Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression. RESULTS: Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations. CONCLUSION: Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

Low impact of regular PCR testing on presence at work site during the COVID-19 pandemic: experiences during an open observational study in Lower Saxony 2020-21.

BACKGROUND: Since social distancing during the COVID-19-pandemic had a profound impact on professional life, this study investigated the effect of PCR testing on on-site work. METHODS: PCR screening, antibody testing, and questionnaires offered to 4,890 working adults in Lower Saxony were accompanied by data collection on demographics, family status, comorbidities, social situation, health-related behavior, and the number of work-related contacts. Relative risks (RR) with 95 % confidence intervals were estimated for the associations between regular PCR testing and other work and health-related variables, respectively, and working on-site. Analyses were stratified by the suitability of work tasks for mobile office. RESULTS: Between April 2020 and February 2021, 1,643 employees underwent PCR testing. Whether mobile working was possible strongly influenced the work behavior. Persons whose work was suitable for mobile office (mobile workers) had a lower probability of working on-site than persons whose work was not suitable for mobile office (RR = 0.09 (95 % CI: 0.07 - 0.12)). In mobile workers, regular PCR-testing was slightly associated with working on-site (RR = 1.19 (0.66; 2.14)). In those whose working place was unsuitable for mobile office, the corresponding RR was 0.94 (0.80; 1.09). Compared to persons without chronic diseases, chronically ill persons worked less often on-site if their workplace was suitable for mobile office (RR = 0.73 (0.40; 1.33)), but even more often if their workplace was not suitable for mobile office (RR = 1.17 (1.04; 1.33)). CONCLUSION: If work was suitable for mobile office, regular PCR-testing did not have a strong effect on presence at the work site. TRIAL REGISTRATION: An ethics vote of the responsible medical association (Lower Saxony, Germany) retrospectively approved the evaluation of the collected subject data in a pseudonymized form in the context of medical studies (No. Bo/30/2020; Bo/31/2020; Bo/32/2020).

[High patient unawareness for chronic kidney disease even in later stages - but why is it more frequent in women than in men?] / Eine chronische Niereninsuffizienz, auch in höherem Stadium, ist Patienten häufig unbekannt ­ aber warum wissen Frauen noch seltener von ihrer Erkrankung als Männer?

INTRODUCTION: Chronic kidney failure (CKD) is as common as diabetes or coronary heart disease in a population aged 40 years and older. Although CKD increases the risk of secondary diseases or premature death, patients with CKD are often unaware of their disease. In a recent analysis of German data, unawareness CKD was higher in women than in men. METHODS: Baseline data from 2010 of 3,305 CKD patients from German cohort studies and registries were analyzed. Stage 1-4 CKD was defined by eGFR (estimated glomerular filtration rate) and albumin-creatinine ratio according to the KDIGO-guideline. Patient knowledge of CKD was coded according to self-report. The proportion of patients without knowledge of CKD and the sex-specific proportion difference (each with 95 % confidence interval) were calculated according to CKD stages and additional comorbidities (diabetes, hypertension, anemia, and cardiovascular disease). In addition, the prevalence ratio (PR) for not knowing about CKD was estimated for women compared to men crude and adjusted for age and other risk factors. RESULTS: Women were less likely than men to know about their CKD in all subgroups studied by age, CKD stage, and comorbidities. The proportion difference for CKD awareness increased with higher CKD stage and was 21 percentage points (7.6; 34.6) at the expense of women in CKD stage 4. Among patients with CKD stage 3b and concomitant grade 2 hypertension, 61 % of women versus 45 % of men were unaware of their disease. The PR for CKD unawareness in women compared with men in the fully adjusted model increased from 1.08 (1.00; 1.16) in CKD stage 3a to 1.75 (1.14; 2.68) in CKD stage 4. CONCLUSION: Despite the presence risk factors that necessitate monitoring of renal function, less than half of patients know they have CKD stage 3b or 4. Women are less likely to be aware of their CKD in all subgroups. Possible causes are gender-related differences in primary health care (gender bias) or in patient-doctor communication.

External validation of six clinical models for prediction of chronic kidney disease in a German population.

BACKGROUND: Chronic kidney disease (CKD) is responsible for large personal health and societal burdens. Screening populations at higher risk for CKD is effective to initiate earlier treatment and decelerate disease progress. We externally validated clinical prediction models for unknown CKD that might be used in population screening. METHODS: We validated six risk models for prediction of CKD using only non-invasive parameters. Validation data came from 4,185 participants of the German Heinz-Nixdorf-Recall study (HNR), drawn in 2000 from a general population aged 45-75 years. We estimated discrimination and calibration using the full model information, and calculated the diagnostic properties applying the published scoring algorithms of the models using various thresholds for the sum of scores. RESULTS: The risk models used four to nine parameters. Age and hypertension were included in all models. Five out of six c-values ranged from 0.71 to 0.73, indicating fair discrimination. Positive predictive values ranged from 15 to 19%, negative predictive values were > 93% using score thresholds that resulted in values for sensitivity and specificity above 60%. CONCLUSIONS: Most of the selected CKD prediction models show fair discrimination in a German general population. The estimated diagnostic properties indicate that the models are suitable for identifying persons at higher risk for unknown CKD without invasive procedures.

High Unawareness of Chronic Kidney Disease in Germany.

Chronic kidney disease (CKD) is associated with an increased risk for cardiovascular events, hospitalizations, end stage renal disease and mortality. Main risk factors for CKD are diabetes, hypertension, and older age. Although CKD prevalence is about 10%, awareness for CKD is generally low in patients and physicians, hindering early diagnosis and treatment. We analyzed baseline data of 3305 participants with CKD Stages 1-4 from German cohorts and registries collected in 2010. Prevalence of CKD unawareness and prevalence ratios (PR) (each with 95%-confidence intervals) were estimated in categories of age, sex, CKD stages, BMI, hypertension, diabetes and other relevant comorbidities. We used a log-binomial regression model to estimate the PR for CKD unawareness for females compared to males adjusting for CKD stage and CKD risk factors. CKD unawareness was high, reaching 71% (68-73%) in CKD 3a, 49% (45-54%) in CKD 3b and still 30% (24-36%) in CKD4. Prevalence of hypertension, diabetes or cardiovascular comorbidities was not associated with lower CKD unawareness. Independent of CKD stage and other risk factors unawareness was higher in female patients (PR = 1.06 (1.01; 1.10)). Even in patients with CKD related comorbidities, CKD unawareness was high. Female sex was strongly associated with CKD unawareness. Guideline oriented treatment of patients at higher risk for CKD could increase CKD awareness. Patient-physician communication about CKD might be amendable.

Statistical Inference in Abstracts Published in Cardiovascular Journals.

BACKGROUND: In 2016, the American Statistical Association stated that the use of statistical significance leads to distortion of the scientific process. The principal alternative to significance or null hypothesis testing (NHT) is estimation with point estimates and confidence intervals (CIs). OBJECTIVES: The aim of this study was to determine the time trend of statistical inference and statistical reporting style in abstracts in major cardiovascular journals. METHODS: A total of 84,250 abstracts published from 1975 to 2019 in 9 high-ranking cardiovascular journals (Circulation, Circulation Research, European Heart Journal, European Heart Journal: Cardiovascular Imaging, European Journal of Heart Failure, Journal of the American College of Cardiology, JACC: Cardiovascular Imaging, JACC: Cardiovascular Interventions, and JAMA Cardiology) were reviewed; in particular, proportions of abstracts containing statistical inference and its major variants (NHT, significance testing) were compared over time and among journals. RESULTS: Overall, 49,924 abstracts (59%) contained statistical inference. Among these abstracts, NHT was the most frequent reporting style of statistical inference (79% among all journals). Journals differed considerably in the prevalence of CI reporting (1% to 78% in 2017-2019). With the exception of 2 journals, the proportion of abstracts containing CIs was higher in the more recent period. From 2013-2015 to 2017-2019, the proportion of abstracts containing only CIs increased by 5 (95% CI: 0 to 10), 18 (95% CI: 15 to 21), and 9 (95% CI: 3 to 15) percentage points in the European Heart Journal, the Journal of the American College of Cardiology, and JACC: Cardiovascular Imaging, respectively. CONCLUSIONS: NHT is still the prevailing reporting style of statistical inference in major cardiovascular journals. Reporting of CIs in abstracts of major cardiovascular journals appears to be growing more popular.

Decline of coronary heart disease mortality is strongly effected by changing patterns of underlying causes of death: an analysis of mortality data from 27 countries of the WHO European region 2000 and 2013.

Mortality rates for coronary heart disease (CHD) experience a longstanding decline, attributed to progress in prevention, diagnostics and therapy. However, CHD mortality rates vary between countries. To estimate whether national patterns of causes of death impact CHD mortality, data from the WHO "European detailed mortality database" for 2000 and 2013 for populations aged ≥ 80 years was analyzed. We extracted mortality rates for total mortality, cardiovascular diseases, neoplasms, dementia and ill-defined causes. We calculated proportions of selected causes of death among all deaths, and proportions of selected cardiovascular causes among cardiovascular deaths. CHD mortality rates were recalculated after re-coding ill-defined causes of death. Association between CHD mortality rates and proportions of CHD deaths was estimated by population-weighted linear regression. National patterns of causes of death were divers. In 2000, CHD was assigned as cause of death in 13-53% of all cardiovascular deaths. Until 2013, this proportion changed between - 65% (Czech Republic) and + 57% (Georgia). Dementia was increasingly assigned as underlying cause of death in Western Europe, but rarely in eastern European countries. Ill-defined causes accounted for between < 1% and 53% of all cardiovascular deaths. CHD mortality rates were closely linked to a countries' proportion of cardiovascular deaths assigned to CHD (R2 = 0.95 for 2000 and 0.99 for 2013). We show that CHD mortality is considerably influenced by national particularities in certifying death. Changes in CHD mortality rates reflect changes in certifying competing underlying causes of death. This must be accounted for when discussing reasons for the CHD mortality decline.

[Increasing Mortality from Cardiac Arrhythmia in Germany?] / Ansteigende Sterblichkeit an Herzrhythmusstörungen in Deutschland?

BACKGROUND: The 'Deutscher Herzbericht 2016' [German Heart Report] reported a strongly increasing mortality rate from cardiac arrhythmia in Germany from 1990 to 2014. The increase was higher in women than in men and was rated as 'paradoxical' in light of improved diagnostic and therapeutic procedures. The aim of this paper is to explore the mortality data for cardiac arrhythmias in detail and to generate an explanatory approach. METHODS: We extracted the number of deaths from cardiac arrhythmia (ICD-10 codes I44-I49) for each sex, 5-year-age group and each federal state for 2000-2014 (www.gbe-bund.de). Crude as well as age-specific and age-standardized (standard: Germany census 2011) mortality rates were calculated. RESULTS: While the crude mortality rates increased considerably between 2000 and 2014 (men: 18 to 26, women: 23 to 38 pro 100,000), the age-standardized mortality rates showed only a small increase (men: 31 to 32, women: 22 to 27 per 100,000 person years). This increase was attributable to an increasing mortality rate from atrial fibrillation and flutter (ICD-10: I48) in men and women aged 80 years and older. In younger age groups and in other subgroups of cardiac arrhythmia, no relevant increases were seen. CONCLUSION: The increase of mortality rates from cardiac arrhythmia as reported in 'Deutscher Herzbericht 2016' is largely attributable to the demographic changes in the German population. After age-standardization, there still remains an increase in the mortality rates, but this is smaller. From an epidemiologic perspective, it is a common problem in the interpretation involving crude mortality data. Moreover, the validity of mortality rates for cardiac arrhythmia is limited due to several reasons.

[Noninformative coding of causes of death in cardiovascular deaths: effects on the mortality rate for ischemic heart disease]. / Nichtinformative Codierungen bei kardiovaskulären Todesursachen: Auswirkungen auf die Mortalitätsrate für ischämische Herzerkrankungen.

BACKGROUND: The validity of mortality statistics is specific to causes of death and depends on the quality of death certificates. The proportion of noninformative underlying causes of death in all deaths is an indicator for the validity of a mortality statistic. The most frequent noninformative cause of death involves cardiovascular diseases (ICD-10: I00-I99). OBJECTIVES: Regional differences in the frequency and type of use of noninformative cardiovascular causes of death are investigated and their effect on the mortality rate of ischemic heart disease is presented. MATERIALS AND METHODS: Mortality rates for cardiovascular causes of death by gender, age group, and federal state were extracted from the Information System of the Federal Health Monitoring (GBE) for 2000, 2010, 2015, and 2016. The proportion of noninformative causes of death in all cardiovascular deaths, as well as the mortality rate for ischemic heart disease after recoding noninformative causes of death, were calculated. RESULTS: The proportion of noninformative causes of death in all cardiovascular deaths is high and depends on age, sex, federal state, and year of death. Regional differences in frequency and type of use were found. After recoding selected noninformative causes of death, the mean increase in the mortality rate for ischemic heart disease in all federal states was 33%. DISCUSSION: A comparison of cause-specific mortality rates between regions, sexes, and over time is affected by differences in the use of noninformative causes of death. Improving the quality of death certificates is a prerequisite for valid mortality statistics.

Self-rated health among migrants from the former Soviet Union in Germany: a cross-sectional study.

OBJECTIVES: To assess the status and change in self-rated health among Aussiedler, ethnic German immigrants from the former Soviet Union, as a predictor for premature death 10 years after first assessment. Moreover, to identify subgroups which are particular at risk of anticipated severe health impairment. DESIGN: Cross-sectional questionnaire. SETTING: The study was conducted in the catchment area of Augsburg, a city in southern Bavaria, Germany, in 2011/2012 that has a large community of Aussiedler. PARTICIPANTS: 595 Aussiedler (231 male, 364 female, mean age 55 years) who in majority migrated to Germany between 1990 and 1999. OUTCOME: Primary outcome: self-rated health (very good/good/not so good/bad) and its association with demographic, social and morbidity related variables. METHODS: Self-rated health was dichotomised as 'very good' and 'good' versus 'not so good' and 'bad'. Multivariable logistic models were created. Missing values with regard to pain were addressed by a second analysis. RESULTS: Although low response suggests a healthier sample, the findings are alarming. Altogether47% of the Aussiedler perceived their health as less than good, which is worse compared with the first assessment in 2000 (25% compared with 20% of the general public). Prevalence of high blood pressure was present in 52% of Aussiedler, 34.5% were obese, 40.7% suffered from frequent pain and 13.1% had diabetes mellitus. According to the multivariable models, individuals suffering from pain, limited mobility, diabetes mellitus and high blood pressure are particularly in jeopardy. CONCLUSIONS: 10 years after the first assessment of self-rated health among Aussiedler their situation deteriorated. Tailored risk factor counselling of general practitioners is highly recommended.